Healthcare Provider Details

I. General information

NPI: 1386103257
Provider Name (Legal Business Name): TRINITY BEHAVIORAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4079 N RANCHO DR STE 160
LAS VEGAS NV
89130-3465
US

IV. Provider business mailing address

4079 N RANCHO DR STE 160
LAS VEGAS NV
89130-3465
US

V. Phone/Fax

Practice location:
  • Phone: 951-640-1276
  • Fax:
Mailing address:
  • Phone: 951-640-1276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: VICTOR CHARLES DRAKE
Title or Position: MANAGER
Credential:
Phone: 951-640-1276